Informed Consent for Jessner’s Peel

Beauty Redefined

408-356-7050

I, ____________________, hereby consent to having my _____________ (site) treated with CHEMICAL PEELING USING JESSNER’S SOLUTION. Jessner’s peeling is often used to treat sun-damaged skin, dark spots, texturally rough skin, acne, and scarring. It is a peeling agent which causes shedding of the outermost layer of skin, “the stratum corneum.”

                    The procedure involves first having the peel site prepped with a pre-peel cleansing agent. The peel is then applied. In general, Jessner’s peels are extremely well tolerated. However, the procedure can cause redness, swelling, flaking, dryness, or irritation in the area to be treated. The effects could last one to two weeks. The treated area will darken before it peels and flakes.  The area will peel about 2-7 days after the treatment.

I understand that there is a small risk of developing permanent darkening or undesirable pigment loss at the treated site. There is rare chance that a scar could develop. There is also a small risk that a bacterial infection could develop or there could be a flare of a pre-existing Herpes infection at the treated site. There is a small chance that the condition being treated could worsen after the peeling procedure. The benefits and side effects of the procedure have been explained to me in detail. All of my questions have been answered.

-I am in stable health.

-I have not used Accutane in the past 6 months.

-I have not used Retin A, hydroquinone, or Obagi products for one week prior to peel.

-I have no allergies to resorcinol, salicyclic acid, or lactic acid.

-I am not pregnant or nursing.

Outcomes are not guaranteed.

 

Signature: ______________________________________ Date: ____________________

 

Witness Signature: ___________________________________ Date: ____________________

 

 

 

 

 

 

Jessner’s Peel Post Instructions

Beauty Redefined

408-356-7050

 

-          Peeling related to Jessner’s usually resolves in 2-7 days.

-          Use bland cleansers and moisturizers (Cetaphil, Aquaphor -any that are unscented, no glycolic or salicylic acid) for up to a week, while the skin is actively peeling, tender, swollen or red.

-          You may resume your normal skin care routine once skin is no longer peeling or tender.

-          You can use makeup to camouflage the peeling and redness.

-          If excessive peeling, redness, or irritation develops after your peel, you may use over the counter 1% Hydrocortisone cream to soothe the skin until resolved.

-          The treated area will darken before it peels and flakes.

 

 

 

Signature: ______________________________ Date: ___________________

 

 

Witness Signature: _________________________________ Date: ________________